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Assessing The Presence of Post-Traumatic Stress and Turnover Intention Among Nurses Post-Middle East Respiratory Syndrome Outbreak
Assessing The Presence of Post-Traumatic Stress and Turnover Intention Among Nurses Post-Middle East Respiratory Syndrome Outbreak
research-article2020
WHSXXX10.1177/2165079919897693Workplace Health & SafetyWorkplace Health & Safety
Original Research
DOI: 10.1177/2165079919897693. From 1Konyang University and 2Seoul Health Foundation. Address correspondence to: Mi Sun Kim, MHA, PhD, Seoul Health Foundation, 31, Maebongsan-ro,
https://doi.org/
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measurement (Karasek et al., 1998) and that of the K-JCQ (Eum 19.0% with 5 to 9 years, and 10.2% with over 10 years of
et al., 2007) was .71; the Cronbach’s alpha in this study was .93. work experience. The majority were staff nurses (91.2%) who
Turnover intention was estimated by the turnover intention worked in rotating shifts (98%). Approximately 37.0% of the
measurement (H. S. Park, 2002), which is the Korean version of nurses worked in either intensive care or in emergency
the scale originally developed by Lawler (1983). The services, whereas 62.6% of them worked in general medicine
measurement consists of four items, each of which is a 5-point departments. The majority of the nurses were single (85.7%)
Likert-type scale (1 = very unlikely, 2 = unlikely, 3 = neutral, and completed 4 years of college or higher (65.3%), and
4 = likely, 5 = very likely). The possible range of scores is from earned an annual salary of more than US$30,000 (62.6%).
4 to 20, with higher scores indicating higher intention to leave. Of the 147 nurses, 33.3% of them were directly involved with
The Cronbach’s alpha for the original measurement was .88 the treatment of confirmed infected patients, whereas 66.7% of
(H. S. Park, 2002) and that of the current study was .84. them were directly involved with the treatment of suspected
The General Health Questionnaire (GHQ) was used to patients. The mental health of the nurses, measured by GHQ,
measure current self-reported mental health. We used the showed the mean score of 28.2 (of 36), indicating problematic
GHQ-12, a reliable and sensitive short form which is ideal for self-rated mental health. The difference of stress levels between
research studies (Liang et al., 2016). The scale consists of 12 every day and the days during the outbreak was 1.34, which
items and is a 4-point Likert-type scale (0 = much less than showed that the stress level during the outbreak was higher.
usual, 1 = same as usual, 2 = more than usual, 3 = much A total of 57.1% (n = 84) of the nurses experienced
more than usual), with a total score ranging from 1 to 36. The PTSD. Considering the score of 25 and above as experiencing
cutoff point in the scores of GHQ-12 is 24, indicating the full PTSD, 25.1% (n = 37) experienced full PTSD and 32.0%
presence of mental health problems (Makowska et al., 2002). (n = 47) experienced some level of PTSD, with scores of 18
The GHQ was included as one of the confounding variables. to 24. The mean score of supervisor support was 10.8 with
To measure the difference of stress levels between the the range of 4 to 19, which indicated moderate supervisor
period of the MERS outbreak and after the outbreak, nurses support. The turnover intention score ranged from 4 to 20,
were asked to recall their stress levels during the MERS and the mean turnover intention in this study was 16.3,
outbreak and compare it with their current day-to-day stress which was high.
levels after the outbreak. A question asking the stress level Table 2 shows the characteristics of participants according to
during the outbreak in a 5-point Likert-type scale and another the PTSD, supervisor support, and turnover intention measures.
question asking the stress level after the outbreak were included Department (p < .05), mental health (p < .01), and the level of
in the survey. The authors, then, calculated the difference involvement during the MERS outbreak (p < .05) were
between the two levels of the stress. associated with post-traumatic stress. Mental health was
negatively associated with supervisor support (p < .01). Years
Data Analysis of work experience (p < .01), shift work (p < .05), marital
status (p < .05), annual income (p < .01), and self-reported
Data were analyzed using the Statistical Package for Social
mental health (negative association, p < .01) were associated
Sciences, Version 20.0 (SPSS, Inc., 2011). The descriptive statistics
with turnover intention.
were calculated using frequency and percentage, as well as
Table 3 shows the results from the multiple regression
means and standard deviation. Cross-tabulation, including t test
analysis in which we observed that nurses with work
and F test, was conducted to examine the characteristics of
experience of between 1 and 4 years (β = .313), direct
participants according to PTSD, supervisor support, and turnover
involvement with the treatment of a suspected patient (β =
intention measures. The relationship between PTSD (independent
.224), and high score of PTSD (β = .188) were positively
variable) and turnover intention (dependent variable), as well as
associated with higher intention to leave. Higher supervisor
the buffering effect of supervisor support as an effect modifier,
support (β = −.395) was, on the contrary, associated with lower
was examined by multiple regression analysis. Work experience,
turnover intention. The interaction between PTSD and
work position, shift work, department, marital status, level of
supervisor support was significant (β = .177) with intention to
education, annual income, mental health status, difference in
leave, illustrating the buffering effect of supervisor support.
stress levels, and level of involvement in the care of MERS
patients were considered as covariates (Jeong et al., 2008; Discussion
Mosadeghrad, 2013; Yang & Kim, 2016).
The purpose of this study was to examine the levels of
PTSD and turnover intention of nurses after the MERS
Results outbreak in Korea. The result showed that 57.1% of the nurses
Table 1 describes the general characteristics of the study who were involved with the direct care of either infected or
participants. Of the 300 invited participants, 152 responded with suspected MERS patients experienced PTSD. In particular,
147 providing usable data (response rate: 49%). 25.1% of the nurses experienced full level of PTSD, which is
All of the participants were female, of which 52.4% had higher than 20.4% of nurses experiencing full level of PTSD
work experience of 1 to 4 years, 18.4% with less than 1 year, using the same IES-R-K from a study on nurses working at
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Workplace Health & Safety July 2020
Table 1. Demographic Characteristics of Nurses Who Worked During an MERS Outbreak (N = 147)
Variables N or M % or SD
Work experience
Work position
Staff nurse 134 91.2
Charge nurse and head nurse 13 8.8
Shift work
No 3 2.0
Yes 144 98.0
Department
Intensive care 27 18.4
Emergency services 27 18.4
General 92 62.6
Others 1 0.7
Marital status
Single 126 85.7
Married 21 14.3
Level of education
3-year college 51 34.7
4-year college or higher 96 65.3
Annual income (US$)
<30,000 92 62.6
≥30,000 55 37.4
(continued)
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Table 1. (continued)
Variables N or M % or SD
PTSD
Full PTSD (scores of 25 and higher) 37 25.1
Moderate/some PTSD (scores 18–24) 47 32.0
No PTSD (scores 0–17) 63 42.9
Supervisor supporta 10.82 2.16
Turnover intentiona 16.29 3.33
Note. MERS = Middle East Respiratory Syndrome; GHQ = General Health Questionnaire; PTSD = post-traumatic stress disorder.
a
Means and standard deviations are present.
emergency departments (Han & Lee, 2013). Another study on effect of social support and higher level of organizational stress
Japanese firefighters using the original IES-R measure showed as well as turnover intention (Nissly et al., 2005). However,
that only 9.7% of the participants experienced full level of majority of studies on buffering effect of social support studies
PTSD (Saijo et al., 2012). A study of medical staff involved were done on the relationship between general or job stress and
with patient care during the SARS outbreak found that 10% of turnover intention, so future studies should be specified on the
the respondents had experienced high levels of PTSD (Wu relationship between PTSD and turnover intention during fetal
et al., 2009). Another study found that around 20% of epidemic events as well as the buffering effect of social support,
participating doctors and nurses showed PTSD symptoms that such as supervisor support.
were involved in the care of Avian influenza A (H7N9)
patients during the H7N9 influenza epidemic in 2015 to 2016 Strengths and Limitations
(Tang et al., 2017). The average turnover intention of nurses Despite the fact that this is one of the few studies on
in this study was 16.29 when the total score range is from 4 nurses who were involved with the direct patient care during
to 20, showing high turnover intention. A previous study that the MERS outbreak in Korea, it has some limitations. Fifteen
used the same measurement revealed average score of 15.41 hospitals were cohort isolated during the MERS breakouts;
among nurses working at emergency department (Lee & Ahn, however, only three hospitals agreed to participated in the
2015). Other studies also showed lower scores compared with study. The small sample size limits our ability to generalize
that of our research, which were 13.75 among nurses working the findings beyond the study hospitals. In addition, the three
at general hospitals (C.-H. Kim et al., 2009) and 9.72 among hospitals that agreed to participate are those that were praised
nurse managers (K. O. Park et al., 2012). by the media for their successful response to the pandemic.
Additional aim of this study was to investigate the relationship Therefore, the levels of PTSD and the buffering effect of
between PTSD and turnover intention. The result of this study supervisor support might have different results if all of 12
validated significant and positive relationship between PTSD and hospitals participated in the research. In addition, data were
turnover intention among nurses who were involved with the care collected after the outbreak due to facility isolation during the
during the MERS outbreak. Prior studies on nurses have presented outbreak. Post-traumatic stress disorder, turnover intention,
the same results. A study on Korean nurses working at emergency and supervisor supports were all asked as recall questions 2
departments revealed significant and positive association between months after the outbreak, introducing possible recall bias.
PTSD and turnover intention (Han & Lee, 2013). Also, after a
traumatic incident, more than 20% of nurses working at
emergency departments displayed high turnover intention. Implication for Occupational Health Nursing
The final investigation was to see whether supervisor support The results of this study are significant and relevant
has buffering effect between PTSD and turnover intention, which because the participants were nurses who were involved with
was proven to be legitimate. Social support of workplace, direct patient care during the MERS outbreak. More than half
including supervisor support, has been known to act as a (57.1%) of the nurses experienced PTSD—25.1% with full level
moderator against the impact of high stress on well-being and and 32.0% with some level of PTSD. Also, PTSD and turnover
related health outcomes on the buffering hypothesis of Cohen intention were significantly and positively related. In addition,
and Wills (1985). Other study has investigated the buffering the results of this study suggest that social support, particularly
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Table 2. Measures of PTSD, Supervisor Support, and Turnover Intention Among Nursing Staff (N = 147)
Main variables
PTSD Supervisor support Turnover intention
(continued)
July 2020
Table 2. (continued)
vol. 68 ■ no. 7
Main variables
PTSD Supervisor support Turnover intention
Note. PTSD = post-traumatic stress disorder; MERS = Middle East Respiratory Syndrome; GHQ = General Health Questionnaire.
**p < .01.
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Table 3. Multiple Regression Analysis Predicting Intent to Leave Among Nursing Staff Employed During MERS Outbreak
Work experience (5–9 years) .167 .097 .101 .284 .073 .435
Work experience (>10 years) .082 .371 .073 .394 .065 .441
Directly involved with the treatment of a suspected patient .220 .006 .221 .003 .224 .003
PTSD .206 .010 .132 .081 .188 .017
Supervisor support −.362 <.000 −.395 <.000
Note. MERS = Middle East Respiratory Syndrome; PTSD = post-traumatic stress disorder.
*p < .05. ***p < .001.
supervisor support, should be provided to reduce the impact Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D.,
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Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering
This study was approved by the Konyang University Hospital
hypothesis. Psychological Bulletin, 98(2), 310–357.
Institutional Review Board (IRB KYUH 2015-09-009-001).
Eum, K. D., Li, J., Jhun, H. J., Park, J. T., Tak, S. W., Karasek, R., & Cho,
Declaration of Conflicting Interests S. I. (2007). Psychometric properties of the Korean version of the Job
Content Questionnaire: Data from health care workers. International
The author(s) declared no potential conflicts of interest with respect Archives of Occupational and Environmental Health, 80(6), 497–504.
to the research, authorship, and/or publication of this article. https://doi.org/10.1007/s00420-006-0156-x
Eun, H. J., Kwon, T. W., Lee, S. M., Kim, T. H., Choi, M. R., & Cho, S. J.
Funding (2005). A study on reliability and validity of the Korean version of
Impact of Event Scale-Revised. Journal of Korean Neuropsychiatric
The author(s) received no financial support for the research, Association, 44(3), 303–310.
authorship, and/or publication of this article.
Han, J. W., & Lee, B. (2013). The relationship of post-traumatic stress, job
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ORCID iD of Korean Academy of Nursing Administration, 19(3), 340–350. https://
Mi Sun Kim https://orcid.org/0000-0003-3970-901X doi.org/10.11111/jkana.2013.19.3.340
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Author Biographies
Occupational Health Nursing, 24(2), 86–93. https://doi.org/10.5807/ Heeja Jung, RN, PhD, earned her master’s and doctoral degrees
kjohn.2015.24.2.86 in nursing from Ewha Womans University. She has years of
Makowska, Z., Merecz, D., Moscicka, A., & Kolasa, W. (2002). The experience working as a nurse in Canada. She is a researcher of
validity of General Health Questionnaires, GHQ-12 and GHQ-28, in a Korea Nurses’ Health Study, the first cohort study on women’s
mental health studies of working people. International Journal of
Occupational Medicine and Environmental Health, 15(4), 353–362.
health. She is currently working as an assistant professor at
College of Nursing, Konyang University.
Ministry of Health and Welfare. (2018). Open Data Portal. https://www.
data.go.kr/emphasisData/show.do
Mosadeghrad, A. M. (2013). Occupational stress and turnover intention: Sun Young Jung, RN, PhD, earned her doctoral degree in
Implications for nursing management. International Journal of Health nursing. She is currently working as an assistant professor at
Policy and Management, 1(2), 169–176. College of Nursing, Konyang University. She was a member of
Nissly, J. A., Barak, M. E. M., & Levin, A. (2005). Stress, social support, the MERS Response Task Force Team when the outbreak first
and workers’ intentions to leave their jobs in public child welfare. occurred in Korea in 2015. She received an award from the
Administration in Social Work, 29(1), 79–100. https://doi.org/10.1300/ Prime Minster in 2016 for her work in the task force team.
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Oyeleye, O., Hanson, P., O’Connor, N., & Dunn, D. (2013). Relationship
of workplace incivility, stress, and burnout on nurses’ turnover
Mi Hyang Lee, RN, PhD, earned her doctoral degree in nursing.
intentions and psychological empowerment. Journal of Nursing She is currently working as an assistant professor at College of
Administration, 43(10), 536–542. https://doi.org/10.1097/ Nursing, Konyang University. She is involved with quality
NNA.0b013e3182a3e8c9 accreditations of local public hospitals.
Park, H. S. (2002). Relationship between perceived nursing care role
orientation, job characteristics, and turnover among nurses [Master’s Mi Sun Kim, MHA, PhD, earned her master’s degree in health
thesis]. Yonsei University.
administration from Missouri State University in the United
Park, K. O., Kim, J. K., Kim, S. Y., & Chang, S. (2012). A model on turnover
States and her PhD in public health from Korea University. She is
intention of chief nurse officers. Journal of Korean Academy of Nursing,
42(1), 9–18. https://doi.org/10.4040/jkan.2012.42.1.9 a former researcher of a Korea Nurses’ Health Study as well as a
Saijo, Y., Ueno, T., & Hashimoto, Y. (2012). Post-traumatic stress disorder
former research professor at Korea University. She is currently
and job stress among firefighters of urban Japan. Prehospital and Disaster working as an Associate Research Fellow at Seoul Health
Medicine, 27(1), 59–63. https://doi.org/10.1017/s1049023x12000222 Foundation.
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